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Laparoscopic Cholecystectomy vs. Open Surgery in the Elderly

Am Fam Physician. 1999 Apr 15;59(8):2322-2323.

The over-80 age group is a rapidly growing segment of the American population. The number of cholecystectomies, particularly those using laparoscopic techniques, is also increasing. Because the increase in laparoscopic cholecystectomies appears to be greatest among patients over 80 years of age, Maxwell and colleagues investigated the safety of laparoscopic cholecystectomy in these patients.

Surgical data for the years 1988 to 1992 from a database of hospitals in 11 states were examined. The database represented approximately 20 percent of U.S. community hospitals. Cholecystectomy was performed on 350,451 patients, of whom 18,500 were at least 80 years of age. Among these very elderly patients, 5,034 procedures were laparoscopic procedures, and 13,466 were open procedures. The number of cholecystectomies in patients 80 years or older increased each year of the study and almost doubled from 1988 to 1992. The proportion of cases performed laparoscopically in these patients rose dramatically, from 8 percent to 64 percent between 1990 and 1992.

In patients older than 80 years, the mortality related to laparoscopic cholecystectomy was significantly lower (1.8 percent) than mortality related to open procedures (4.4 percent). Laparoscopic procedures were found to have one half the mortality rate of open procedures in each age subset of this population. Men had a mortality rate of 2.1 percent with a laparoscopic procedure and 4.8 percent with open cholecystectomy. Women had slightly lower mortality rates: 1.6 percent with laparoscopy and 4.1 percent with open cholecystectomy. Lengths of hospital stay were lower for both male and female patients following laparoscopic cholecystectomy (7.9 days for men and 6.9 days for women, compared with 11.3 and 11.0 days for open cholecystectomy). Patients were significantly more likely to be discharged to skilled nursing facilities following open procedures (11 percent) compared with laparoscopic cholecystectomy (8 percent). Seventy-five percent of patients undergoing laparoscopic cholecystectomy were discharged home, compared with 68 percent of those treated with open procedures, but this difference was not statistically significant.

The authors conclude that laparoscopic cholecystectomy has low mortality and morbidity rates even in very elderly patients. The trends over time may reflect increasing surgical experience and a willingness to intervene earlier in the course of disease. They suggest that laparoscopic cholecystectomy could be offered early to elderly patients with symptomatic gall bladder disease.